HospitalInspections.org

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas in the following locations:
*The laboratory at the roll-up corridor door.
*The ambulance garage at the two hour fire barrier wall above the lay-in ceiling.
Findings include:

1. Interview beginning at 10:00 a.m. revealed the one hour fire-rated roll-up door to the corridor on the west end of the laboratory would not close automatically with the activation of the building's automatic fire alarm. Interview with the director of environmental services at the time of the observation confirmed that finding. He stated that fire-rated roll-up door had been installed within the last year. He further stated although he had called an electrician several times to connect this door to the fire alarm system, they had not yet been to the facility.

2. Observation at 11:21 a.m. revealed a water pipe created a hole in the fire barrier wall between the ambulance garage and the hospital's main corridor system. Interview with the director of environmental services at the time of the observation confirmed that finding.

Based on observation, interview, and document review, the provider failed to maintain the width of corridors (clear and unobstructed) that served exit access by keeping a folding table, two chairs, and an equipment cart in the south west corridor. Findings include:

1. Observation beginning from 9:00 a.m. until 3:45 p.m. revealed a folding table, two chairs, and an equipment cart were stored in the south west corridor to the west of the nurses station. Interview with the director of environmental services at 3:45 p.m. confirmed that condition. He stated that condition only occurred for one day a month when the visiting doctor was in the facility seeing patients.

Interview with the administrator at the time of the exit interview revealed that item had been cited as a deficiency during the last survey. He stated their plan of correction for that citation from the previous survey addressed that deficiency. Document review of the Department Of Health record of the previous survey's plan of correction revealed that condition had been cited as a result of the last survey. The plan of correction for that citation stated "Any equipment used by the outreach doctors will be confined to examination rooms only."

Based on observation, testing, and interview, the provider failed to maintain a 90 minute door in a horizontal exit door in operating condition. One randomly observed 90 minute fire rated door between the 1970 addition and the 1993 addition did not function properly. Findings include:

1. Observation and testing at 10:24 a.m. on 6/22/10 revealed the 90 minute fire rated door between business office and the office would not fully close and latch under the power of the door closer when tested on three of three attempts. That door existed within a two-hour fire wall that was also used to form a horizontal exit. Interview with the director of environmental services at the time of the observation revealed he had not recently checked that door's operation.

Based on interview, the provider failed to ensure emergency lighting of at least 90 minute duration was provide at all times. Findings include:

1. Interview with the environmental services director at 6:17 on 6/22/10 revealed he did not have testing of all three emergency lights attached to all three exit signs on the preventive maintenance schedule. He stated he did not have a written schedule for the required monthly and yearly tests required for those devices.

A. Based on interview, the provider failed to maintain all exit signs with a properly maintained back-up power source. Exit signs connected to or provided with battery-operated emergency illumination source shall be tested and maintained in accordance with section 7.9.3 of the Life Safety Code. Findings include:

1. Interview with the environmental services director at 10:15 a.m. on 6/22/10 revealed the facilities battery back-up exit signs had not been tested for proper operation on battery power. He indicated he did not perform yearly 90 minute tests or log any monthly inspections. When asked if the exit signs were on the preventative maintenance schedule he stated the provider had no log for testing exit signs.

B. Based on observation and interview, the provider failed to maintain one randomly observed exit sign with continuous illumination. Findings include:

1. Observation at 11:15 a.m. on 6/22/10 revealed the exit sign for the east exit of the ambulance garage was not illumined. Interview with the director of environmental services at the time of the observation confirmed that condition. He stated he believed the lamps had burnt out. He indicated he would replace the burned out lamps immediately. When asked if that exit sign was on the preventative maintenance schedule he stated the provider had no log for checking the exit signs.

Based on interview, the provider failed to maintain all exit signs with a properly maintained back-up power source. Exit signs connected to or provided with battery-operated emergency illumination source shall be tested and maintained in accordance with section 7.9.3 of the Life Safety Code. Findings include:

1. Interview with the environmental services director at 6:15 p.m. on 6/22/10 revealed the facilities three battery back-up exit signs had not been tested for proper operation on battery power. He indicated he did not perform yearly 90 minute tests or log any monthly inspections. When asked if the exit signs were on the preventative maintenance schedule he stated the provider had no log for testing exit signs.

A. Based on observation and interview, the provider failed to ensure one staff person was familiar with fire drill procedures. Findings include:

1. Observation at 3:58 p.m. revealed a nurse responded to a fire drill. That nurse located the fire within the patient room and immediately proceeded to find a manual pull station and announced the "Code Red". The nurse failed to pull the door closed to isolate the effects of the simulated fire. That door remained open for approximately 45 seconds until another staff person came down the corridor to close all open corridor doors. Interview with the director of environmental services at the time of the observation confirmed that door had not been properly closed to isolate the effects of the simulated fire.

B. Based on record review and interview, the provider failed to conduct quarterly fire drills for each shift during three of the four previous quarters. Findings include:

1. Fire drill record review on 6/22/10 revealed no documentation indicating a fire drill had been conducted during the April-June 2009 quarter and in the July-September 2009 quarter for the 7:00 a.m. to 7:00 p.m. shift. Likewise there was no documentation indicating a fire drill had been conducted during the October-December 2009 quarter for the 7:00 p.m. to 7:00 a.m. shift. Interview with the director of environmental services at the time of the record review revealed he had missed the fire drills during those quarters.

Based on observation and interview, the provided failed to install signaling devices that provided effective warning of fire in one smoke compartment (eastern smoke compartment of the 1970 addition). Findings include:

1. Observation at 3:58 p.m. during the fire drill revealed the eastern smoke compartment of the 1970 addition did not contain a signaling device. Further observation revealed that when the cross corridor smoke barrier doors closed the alarm in the smoke compartment without a signaling device was barely audible. Interview with the director of environmental services at the time of the observation confirmed that condition. He stated the signaling devices were not sufficiently audible during the fire drill.

Based on observation and interview, the provider failed to perform monthly checks of fire extinguishers in accordance with NFPA 10. Monthly checks had not been performed for the last eight months for all fire extinguishers. Findings include:

1. Random observation at 5:52 p.m. revealed both fire extinguishers in the physical therapy clinic did not have any monthly maintenance checks written on the fire extinguisher tags since the annual inspection in September of 2009.

Interview with the maintenance director at the time of the observation confirmed that finding. When asked if that extinguisher was on the preventative maintenance schedule he stated the provider had no log for checking the extinguishers other than the tag hanging on each extinguisher.

Based on observation and interview, the provider failed to perform monthly checks of fire extinguishers in accordance with NFPA 10. Monthly checks had not been performed on one randomly checked fire extinguisher in the mechanical room for the last two months. Findings include:

1. Observation at 3:00 p.m. revealed the fire extinguishers in the mechanical room did not have any monthly maintenance checks written on the fire extinguisher tag since 3/31/10.

Interview with the maintenance director at the time of the observation confirmed that finding. When asked if that extinguisher was on the preventative maintenance schedule he stated the provider had no log for checking the extinguishers other than the tag hanging on each extinguisher.

A. Based on record review and interview, the provider failed to ensure the required inspection of the cooking facility's fire extinguishing system was taking place. Inspections of the fire suppression system for the range hood must be conducted not less than every six months. Findings include:

1. Record review revealed the fire suppression system for the kitchen hood had last been inspected on 9/30/09. Interview with the director of environmental services at the time of observation confirmed that condition.

B. Based on observation and staff interview, the provider failed to install and use baffle type filters in the stove exhaust hood in accordance with NFPA 96. Findings include:

1. Observation at 3:21 p.m. revealed the kitchen stove exhaust hood had mesh type filters in the overhead exhaust duct. Baffle type exhaust filters are required for the kitchen range hood exhaust system. Interview with the director of environmental services at the time of the observation revealed he had known the provider to only use the wire mesh filters for the exhaust system.

Based on observation and interview, the provider failed to maintain the width of one randomly observed corridor (clear and unobstructed) that served as an exit access for the south exit corridor. Findings include:

1. Observation at 10:51 a.m. revealed a storage cabinet was stored in the exit corridor in the east exit corridor by the main entrance. That item projected into the corridor and restricted the corridor width to six feet nine inches instead of the required eight foot.

Interview with the director of environmental services at time of the observation confirmed that condition. He stated that storage cabinet was used as a "swing bed closet" that housed items for sale as a fundraiser for swing bed patients.

Based on interview and record review, the provider failed to maintain the generator in accordance with NFPA 110 Chapter 6 Routine Maintenance and Operational Testing. Findings include:

1. Interview with the director of environmental services at 10:30 a.m. revealed the provider had not been conducting the required testing of the emergency back-up generator. He stated they had not been conducting monthly 30 minute load tests since the generator log book had gotten wet. Record review of that log book at revealed the last recorded test of the generator had occurred on 11/30/07.

The provider must comply with National Fire Protection Association (NFPA) 70 article 305-Temporary Wiring (See attachment.)

Based on observation and interview, the provider failed to furnish permanent wiring. A power strip was in-use in place of permanent wiring in the medical records office. Findings include:

1. Observation at 10:41 a.m. revealed a power strip was in-use in place of permanent wiring in the medical records office. That power strip was used to power a multi-function copier machine and a wireless router. Interview with the director of environmental services at the time of the observation confirmed that condition. He stated they had just installed thatmulti-function copier machine and wireless router, and he was unaware of the use of that power strip.

Based on observation and interview, the provider failed to properly install alcohol based hand rub (ABHR) containers at four randomly observed locations (X-ray room, emergency room, patient room 101, and patient room 105). ABHR was found over or adjacent to light switches. Findings include:

1. Observation from 9:55 a.m. to 3:38 p.m. on revealed ABHR containers were installed over light switches in the X-ray room, emergency room, patient room 101, and patient room 105. Interview with the director of environmental services at the time of the observations confirmed those findings. He stated he was unaware when those ABHR dispensers were placed into service. He further stated he was unaware of that requirement.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas in the following locations:
*The laboratory at the roll-up corridor door.
*The ambulance garage at the two hour fire barrier wall above the lay-in ceiling.
Findings include:

1. Interview beginning at 10:00 a.m. revealed the one hour fire-rated roll-up door to the corridor on the west end of the laboratory would not close automatically with the activation of the building's automatic fire alarm. Interview with the director of environmental services at the time of the observation confirmed that finding. He stated that fire-rated roll-up door had been installed within the last year. He further stated although he had called an electrician several times to connect this door to the fire alarm system, they had not yet been to the facility.

2. Observation at 11:21 a.m. revealed a water pipe created a hole in the fire barrier wall between the ambulance garage and the hospital's main corridor system. Interview with the director of environmental services at the time of the observation confirmed that finding.

Based on observation, interview, and document review, the provider failed to maintain the width of corridors (clear and unobstructed) that served exit access by keeping a folding table, two chairs, and an equipment cart in the south west corridor. Findings include:

1. Observation beginning from 9:00 a.m. until 3:45 p.m. revealed a folding table, two chairs, and an equipment cart were stored in the south west corridor to the west of the nurses station. Interview with the director of environmental services at 3:45 p.m. confirmed that condition. He stated that condition only occurred for one day a month when the visiting doctor was in the facility seeing patients.

Interview with the administrator at the time of the exit interview revealed that item had been cited as a deficiency during the last survey. He stated their plan of correction for that citation from the previous survey addressed that deficiency. Document review of the Department Of Health record of the previous survey's plan of correction revealed that condition had been cited as a result of the last survey. The plan of correction for that citation stated "Any equipment used by the outreach doctors will be confined to examination rooms only."

Based on observation, testing, and interview, the provider failed to maintain a 90 minute door in a horizontal exit door in operating condition. One randomly observed 90 minute fire rated door between the 1970 addition and the 1993 addition did not function properly. Findings include:

1. Observation and testing at 10:24 a.m. on 6/22/10 revealed the 90 minute fire rated door between business office and the office would not fully close and latch under the power of the door closer when tested on three of three attempts. That door existed within a two-hour fire wall that was also used to form a horizontal exit. Interview with the director of environmental services at the time of the observation revealed he had not recently checked that door's operation.

Based on interview, the provider failed to ensure emergency lighting of at least 90 minute duration was provide at all times. Findings include:

1. Interview with the environmental services director at 6:17 on 6/22/10 revealed he did not have testing of all three emergency lights attached to all three exit signs on the preventive maintenance schedule. He stated he did not have a written schedule for the required monthly and yearly tests required for those devices.

A. Based on interview, the provider failed to maintain all exit signs with a properly maintained back-up power source. Exit signs connected to or provided with battery-operated emergency illumination source shall be tested and maintained in accordance with section 7.9.3 of the Life Safety Code. Findings include:

1. Interview with the environmental services director at 10:15 a.m. on 6/22/10 revealed the facilities battery back-up exit signs had not been tested for proper operation on battery power. He indicated he did not perform yearly 90 minute tests or log any monthly inspections. When asked if the exit signs were on the preventative maintenance schedule he stated the provider had no log for testing exit signs.

B. Based on observation and interview, the provider failed to maintain one randomly observed exit sign with continuous illumination. Findings include:

1. Observation at 11:15 a.m. on 6/22/10 revealed the exit sign for the east exit of the ambulance garage was not illumined. Interview with the director of environmental services at the time of the observation confirmed that condition. He stated he believed the lamps had burnt out. He indicated he would replace the burned out lamps immediately. When asked if that exit sign was on the preventative maintenance schedule he stated the provider had no log for checking the exit signs.

Based on interview, the provider failed to maintain all exit signs with a properly maintained back-up power source. Exit signs connected to or provided with battery-operated emergency illumination source shall be tested and maintained in accordance with section 7.9.3 of the Life Safety Code. Findings include:

1. Interview with the environmental services director at 6:15 p.m. on 6/22/10 revealed the facilities three battery back-up exit signs had not been tested for proper operation on battery power. He indicated he did not perform yearly 90 minute tests or log any monthly inspections. When asked if the exit signs were on the preventative maintenance schedule he stated the provider had no log for testing exit signs.

A. Based on observation and interview, the provider failed to ensure one staff person was familiar with fire drill procedures. Findings include:

1. Observation at 3:58 p.m. revealed a nurse responded to a fire drill. That nurse located the fire within the patient room and immediately proceeded to find a manual pull station and announced the "Code Red". The nurse failed to pull the door closed to isolate the effects of the simulated fire. That door remained open for approximately 45 seconds until another staff person came down the corridor to close all open corridor doors. Interview with the director of environmental services at the time of the observation confirmed that door had not been properly closed to isolate the effects of the simulated fire.

B. Based on record review and interview, the provider failed to conduct quarterly fire drills for each shift during three of the four previous quarters. Findings include:

1. Fire drill record review on 6/22/10 revealed no documentation indicating a fire drill had been conducted during the April-June 2009 quarter and in the July-September 2009 quarter for the 7:00 a.m. to 7:00 p.m. shift. Likewise there was no documentation indicating a fire drill had been conducted during the October-December 2009 quarter for the 7:00 p.m. to 7:00 a.m. shift. Interview with the director of environmental services at the time of the record review revealed he had missed the fire drills during those quarters.

Based on observation and interview, the provided failed to install signaling devices that provided effective warning of fire in one smoke compartment (eastern smoke compartment of the 1970 addition). Findings include:

1. Observation at 3:58 p.m. during the fire drill revealed the eastern smoke compartment of the 1970 addition did not contain a signaling device. Further observation revealed that when the cross corridor smoke barrier doors closed the alarm in the smoke compartment without a signaling device was barely audible. Interview with the director of environmental services at the time of the observation confirmed that condition. He stated the signaling devices were not sufficiently audible during the fire drill.

Based on observation and interview, the provider failed to perform monthly checks of fire extinguishers in accordance with NFPA 10. Monthly checks had not been performed for the last eight months for all fire extinguishers. Findings include:

1. Random observation at 5:52 p.m. revealed both fire extinguishers in the physical therapy clinic did not have any monthly maintenance checks written on the fire extinguisher tags since the annual inspection in September of 2009.

Interview with the maintenance director at the time of the observation confirmed that finding. When asked if that extinguisher was on the preventative maintenance schedule he stated the provider had no log for checking the extinguishers other than the tag hanging on each extinguisher.

Based on observation and interview, the provider failed to perform monthly checks of fire extinguishers in accordance with NFPA 10. Monthly checks had not been performed on one randomly checked fire extinguisher in the mechanical room for the last two months. Findings include:

1. Observation at 3:00 p.m. revealed the fire extinguishers in the mechanical room did not have any monthly maintenance checks written on the fire extinguisher tag since 3/31/10.

Interview with the maintenance director at the time of the observation confirmed that finding. When asked if that extinguisher was on the preventative maintenance schedule he stated the provider had no log for checking the extinguishers other than the tag hanging on each extinguisher.

A. Based on record review and interview, the provider failed to ensure the required inspection of the cooking facility's fire extinguishing system was taking place. Inspections of the fire suppression system for the range hood must be conducted not less than every six months. Findings include:

1. Record review revealed the fire suppression system for the kitchen hood had last been inspected on 9/30/09. Interview with the director of environmental services at the time of observation confirmed that condition.

B. Based on observation and staff interview, the provider failed to install and use baffle type filters in the stove exhaust hood in accordance with NFPA 96. Findings include:

1. Observation at 3:21 p.m. revealed the kitchen stove exhaust hood had mesh type filters in the overhead exhaust duct. Baffle type exhaust filters are required for the kitchen range hood exhaust system. Interview with the director of environmental services at the time of the observation revealed he had known the provider to only use the wire mesh filters for the exhaust system.

Based on observation and interview, the provider failed to maintain the width of one randomly observed corridor (clear and unobstructed) that served as an exit access for the south exit corridor. Findings include:

1. Observation at 10:51 a.m. revealed a storage cabinet was stored in the exit corridor in the east exit corridor by the main entrance. That item projected into the corridor and restricted the corridor width to six feet nine inches instead of the required eight foot.

Interview with the director of environmental services at time of the observation confirmed that condition. He stated that storage cabinet was used as a "swing bed closet" that housed items for sale as a fundraiser for swing bed patients.

Based on interview and record review, the provider failed to maintain the generator in accordance with NFPA 110 Chapter 6 Routine Maintenance and Operational Testing. Findings include:

1. Interview with the director of environmental services at 10:30 a.m. revealed the provider had not been conducting the required testing of the emergency back-up generator. He stated they had not been conducting monthly 30 minute load tests since the generator log book had gotten wet. Record review of that log book at revealed the last recorded test of the generator had occurred on 11/30/07.

The provider must comply with National Fire Protection Association (NFPA) 70 article 305-Temporary Wiring (See attachment.)

Based on observation and interview, the provider failed to furnish permanent wiring. A power strip was in-use in place of permanent wiring in the medical records office. Findings include:

1. Observation at 10:41 a.m. revealed a power strip was in-use in place of permanent wiring in the medical records office. That power strip was used to power a multi-function copier machine and a wireless router. Interview with the director of environmental services at the time of the observation confirmed that condition. He stated they had just installed thatmulti-function copier machine and wireless router, and he was unaware of the use of that power strip.